Why you should create a prone positioning team at a time of crisis in intensive care

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Editor, With the coronavirus disease 2019 (COVID-19) outbreak, a large number of patients were admitted to intensive care units (ICUs) for an acute respiratory distress syndrome (ARDS). Prone positioning is recommended by experts as adjuvant treatment for severe COVID-related ARDS, despite a lack of data regarding its effect.1,2 Our three ICU teams (Medical, Surgical, Cardiac, in total 59 beds) were rapidly overwhelmed, requiring the entire hospital to reorganise. Elective surgery was cancelled, freeing up anaesthetists and other staff, as well as enabling two recovery wards to become ICUs with a third ICU created in our cardiology unit. The freed-up anaesthetists, senior surgical residents and nurses redeployed from conventional wards helped to staff these three new ICUs, providing an additional 52 ventilator beds for critically ill patients requiring mechanical ventilation. Prone positioning (i.e. turning patients from dorsal to prone position and vice versa) was becoming a frequent process, which with the logistics of freeing up five ICU staff simultaneously and the strict asepsis protocols in place, were difficult to organise and very time consuming. Thus, to ensure the best continuous care for all the ICU patients within the organisational constraints of the pandemic crisis, it was decided to create a dedicated team to perform prone positioning. In addition to one ICU doctor to co-ordinate the process, the prone team consisted of four people: one surgical resident and one operating room nurse formed the core of the team and they were supplemented with two more personnel, a mixture of medical students and/or operating room technicians. The formation of the prone team enabled a daily availability of the team during the whole crisis and provided proficient prone positioning expertise for the unconscious patients. As well as training in the use of the prone positioning technique (https://www.youtube.com/watch?v=lcBPaHQUvXY&ab_channel=RushUniversitySystemforHealth), the team members also undertook a complementary course on hygiene and protective equipment. A protocol was written to guarantee the reproducibility of practice. The prone team was operational from 8:00 a.m. to 10:30 p.m., divided in two shifts. All prone positioning outside these hours was performed by ICU personnel alone. One month after the end of the prone team, all prone team members completed a questionnaire to assess possible infection with COVID-19 or any injury related to prone positioning manoeuvers. The patient's follow-up data consisted of assessing the number of reintubation because of endotracheal tube displacement or obstruction, pressure sores (from skin abrasions to ischemic lesions needing surgical debridement), facial oedema, corneal abrasions and brachial plexus injuries. The aim of this study was to observe the impact of the prone team on the workload in the ICU. All patients requiring prone positioning from 25 March to 23 April 2020 were included in this observational study. The end of the study period was when the three additional ICUs were closed down. Two hundred and eighty-eight COVID-19 patients were admitted to the ICU of the Nouvel Hôpital Civil, Strasbourg, France. Among them, 100 patients required prone positioning and benefited from at least one prone positioning by the prone team. During the observations period, 586 prone positionings (ventral to dorsal or dorsal to ventral) were performed in the period, with 455 of these undertaken by the prone team. Twenty-one surgical residents and 26 medical students volunteered, and performed a median [IQR] number of 2 [1.0 to 3.5] and 3 [1.0 to 6.0] shifts respectively during the period. Four operating room nurses and one operating room technician were redeployed from their usual role to join the prone team, and respectively performed 14 [10.25 to 20.75] and 13 shifts. The median [IQR] patient body weight per mobilisation was 89 [76 to 99] kg giving a total median weight mobilised per day of 1703 [1281 to 2752] kg. ICU physicians estimated that a traditional prone positioning performed by ICU staff lasted 30 min. With a median of eight prone positioning procedures per shift, the prone team became able to perform a prone positioning manoeuvre in a mean time of 15 min. Thus, total estimated non-ICU staff time required for these 455 mobilisations lay between 455 and 910 h. However, irrespective of the time the prone team required for a prone positioning procedure, the prone team allowed a prone positioning manoeuvre to take place expeditiously and at the same time allowed experienced ICU staff to concentrate on other essential tasks. With the number of ICU staff hours saved by the prone team and the efficiency of the prone positioning process, the effectiveness of the prone team on organisational matters within the ICU is without question. No member of the prone positioning team developed COVID-19 symptoms, and there were no staff injuries related to moving the patients. Given the physical requirement of this activity with a considerable patient weight to be mobilised every day, it was important to ensure a steady turn-over of staff among the prone team members so as to share the workload. With the benefits of the prone team outlined above and no staff injuries, only consideration of patient outcomes remain. Eight patients required re-intubation because of endotracheal tube obstruction and two tubes required repositioning because of displacement. Neither vascular line displacements occurred nor was haemodynamic instability observed. No corneal abrasions or brachial plexus injuries were observed. However, three patients (3%) suffered from a transient facial oedema and 64 (64%) patients developed pressure sores or skin abrasions: of these, 62 (97%) were located in the facial area. One patient developed lip necrosis, necessitating surgical intervention by the plastic surgeons. This latter was the only major complication. Girard et al.3 specifically focused on pressure sores in prone positioning and found a 44.4% risk of developing pressure ulcers including 18.4% in the facial area. The main risks factors included age more than 60 years and a body mass index greater than 28 kg m−2. Although, our population presented these risk factors, that alone does not explain the large number of pressure ulcers in our population. We can only speculate that this may be partially because of the lack of appropriate equipment in the three additional ICUs as 76% of the cases occurred in these three units. These additional ICU beds were equipped only with regular mattresses. With the rapid increase in daily positioning, most patients were eventually positioned on regular pillows for the body (one under the upper thorax and one under the pelvic area) and surgical foam for the head. Despite similar care in each of the ICU wards, patients in the standard ICUs with appropriate beds and mattresses developed fewer pressure sores than those cared for in the new ICUs equipped with normal ward beds, mattresses and pillows. The main findings of this study were that patients suffering from COVID-19 required a large number of prone positioning manoeuvres, exceeding the usual resources of ICU staff; the creation of dedicated prone teams allowed a substantial time saving for ICU staff, allowing them to concentrate on other highly skilled task; no long-lasting complications occurred during the prone positioning, although a significant number of pressure sores were observed.

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